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National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention 

Division of Tuberculosis Elimination

TB Elimination

Infection Control in Health-Care Settings 

Introduction

All health-care settings need an infection-control 

program designed to ensure the following:

• Prompt detection of infectious patients; 

• Airborne precautions; and 

• Treatment of people who have suspected or 

confirmed tuberculosis (TB) disease.

In order to be effective, the primary emphasis of 

the TB infection-control program should be on 

achieving these three goals. 

In all health-care settings, particularly those in 

which persons who are at high risk for exposure to 

Mycobacterium tuberculosis work or receive care, 

policies and procedures for TB control should be 

developed, reviewed periodically, and evaluated for 

effectiveness to determine the actions necessary to 

minimize the risk for transmission of M. tuberculosis.

Overview of TB Infection-Control 

Measures

The TB infection-control program should be based 

on a three-level hierarchy of control measures and 

include:

1. Administrative controls

2. Environmental controls

3. Use of respiratory protective equipment

The first and most important level of the hierarchy, 

administrative controls, impacts the largest number 

of people and is intended primarily to reduce the 

risk of uninfected people exposed to people who 

have TB disease. These control measures include the 

following activities: 

• Assigning responsibility for TB infection control 

in the setting; 

• Conducting a TB risk assessment of the setting;

• Developing and instituting a written TB 

infection-control plan to ensure prompt 

detection, airborne precautions, and treatment 

of persons who have suspected or confirmed 

TB disease; 

• Ensuring the timely availability of 

recommended laboratory processing, testing, 

and reporting of results to the ordering 

physician;

• Implementing effective work practices for the 

management of patients with suspected or 

confirmed TB disease; 

• Ensuring proper cleaning and sterilization 

or disinfection of potentially contaminated 

equipment (e.g., bronchoscopes, endoscopes);

• Training and educating health-care workers 

(HCWs) regarding TB, with specific focus on 

prevention, transmission, and symptoms;

• Screening and evaluating HCWs who are at 

risk for TB disease or who might be exposed to 

M. tuberculosis;

• Applying epidemiologic-based prevention 

principles, including the use of setting-related 

infection-control data;

• Using appropriate signage advising respiratory 

hygiene and cough etiquette; and

• Coordinating efforts with the local or state 

health department. 

The second level of the hierarchy is the use of 

environmental controls to prevent the spread and 

reduce the concentration of infectious droplet 

nuclei in ambient air. Primary environmental 

controls control the source of infection by 

using local exhaust ventilation (hoods, tents, or 

booths) and dilute and remove contaminated 

air by using general ventilation. Secondary 

environmental controls control the airflow to 

prevent contamination of air in areas adjacent 

to the source (airborne infection isolation [AII] 

rooms) and clean the air by using high efficiency 

particulate air (HEPA) filtration, or ultraviolet 

germicidal irradiation.
May 2012

The first two control levels of the hierarchy 

minimize the number of areas in the health-care 

setting where exposure to M. tuberculosis may 

occur. They reduce, but do not eliminate, the risk in 

those few areas where exposure to M. tuberculosis 

can still occur (e.g., AII rooms housing TB patients 

and treatment rooms in which cough-inducing or 

aerosol-generating procedures are performed on TB 

patients). Therefore, the third level of the hierarchy 

is the use of respiratory protective equipment 

in situations that pose a high risk of exposure to 

M. tuberculosis. 

Use of respiratory protection equipment can further 

reduce risk for exposure of HCWs to infectious 

droplet nuclei that have been expelled into the 

air from a patient with infectious TB disease. The 

following measures can be taken to reduce the risk 

for exposure: 

• Implementing a respiratory protection program; 

• Training HCWs on respiratory protection; and 

• Training patients on respiratory hygiene and 

cough etiquette procedures. 

Determining the Infectiousness of 

TB Patients

In general, patients who have suspected or 

confirmed TB disease should be considered 

infectious if:

a. They are coughing, undergoing cough-inducing 

procedures, or have positive sputum smear 

results for acid-fast bacilli (AFB); and 

b. They are not receiving adequate 

antituberculosis therapy, have just started 

therapy, or have a poor clinical or bacteriologic 

response to therapy.

For patients placed under airborne precautions 

because of suspected infectious TB disease of the 

lungs, airway, or larynx, airborne precautions can 

be discontinued when infectious TB disease is 

considered unlikely and either: 

• Another diagnosis is made that explains the 

clinical syndrome; or 

• The patient produces three consecutive 

negative sputum smears collected in 8 to 

24-hour intervals (one should be an early 

morning specimen). 

Patients for whom the suspicion of infectious 

TB disease remains after the collection of three 

negative sputum smear results should not be 

released from airborne precautions until they: 

• Receive standard multidrug antituberculosis 

treatment (minimum of 2 weeks); and 

• Demonstrate clinical improvement. 

• For these patients, additional diagnostic 

approaches (e.g., sputum induction) and, after 

sufficient time on treatment, bronchoscopy 

may need to be considered.

• Patients who have drug-susceptible TB of the 

lung, airway, or larynx, should remain under 

airborne precautions until they:

• Produce three consecutive negative sputum 

smears collected in 8 to 24-hour intervals (one 

should be an early morning specimen) 

• Receive standard multidrug antituberculosis 

treatment (minimum of 2 weeks); and 

• Demonstrate clinical improvement. 

Note: The Centers for Disease Control and Prevention (CDC) is not a regulatory agency; CDC recommendations on infection control provide evidence-based guidance. For regulations in your area, refer 

to state and local regulations and contact your local Occupational Safety and Health Administration 

(OSHA) office. A directory of OSHA offices may be found at http://www.osha.gov/html/RAmap.html.

References

CDC. Guidelines for preventing the transmission 

of Mycobacterium tuberculosis in health-care 

settings, 2005. MMWR 2005; 54(No. RR-17). 

www.cdc.gov/mmwr/pdf/rr/rr5417.pdf

Additional Information

1. CDC Division of TB: www.cdc.gov/tb

2. State TB Control Offices: http://www.cdc.gov/

tb/links/tboffices.htm

3. National Institute for Occupational Safety and 

Health: http://www.cdc.gov/niosh/topics/tb/

4. OHSA: http://www.osha.gov/SLTC/tuberculosis/

index.html

5. Respiratory Protection in Health-Care Settings: 

www.cdc.gov/tb/publications/factsheets/

prevention/rphcs.htm

http://www.cdc.gov/tb